Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at South County Eden Operations Llc Dba Lakeside Nurs during CMS and state inspections, most recent first.
Failure to notify residents or their representatives in writing when personal needs fund balances neared the SSI resource limit. Record review showed three residents with facility-managed funds exceeded the $4,000 Medicaid eligibility guideline, and the BOM could not provide evidence that written notice was given when balances reached $200 below the limit.
Late and Missing MDS Assessments: The facility failed to complete and transmit several MDS assessments within required timeframes for multiple residents, including quarterly and annual assessments for residents with hx of stroke, lung cancer, COPD, depression, and type II DM. The facility also failed to complete a required SCSA for a resident enrolled in hospice and failed to complete a discharge MDS for another resident. The MDS coordinator acknowledged the late completion and transmission of the assessments.
Failure to replace CPAP and BiPAP supplies per manufacturer guidance affected 3 residents with OSA and, for 2 residents, COPD. Records showed orders to clean and use the devices, but no evidence of orders to replace filters, masks, tubing, mask frames, chin straps, or humidifier water chambers as recommended. One resident reported using a mask from before admission, and the DON could not provide evidence that the equipment had been or was scheduled to be replaced.
Failure to provide written notice before room or roommate changes: Two residents were involved when an Admissions Director moved one resident's belongings into another resident's room and changed the other resident's room while that resident was out for an appt. One resident had dementia with a BIMS of 12, and the other had intact cognition with a BIMS of 15. Neither resident had documented prior written notice or, for the room change, documented consent before the move.
Failure to document ordered PICC line measurements. A resident with a PICC line and a diagnosis including sepsis due to MSSA had physician orders for weekly dressing changes and for external catheter length and arm circumference measurements. The record showed incomplete and missing documentation of the ordered measurements, and the RN stated the measurements were completed but not documented in the TAR; the DON could not provide evidence that the measurements were done weekly as ordered.
A resident with CKD and HTN had an order for metoprolol succinate with SBP hold parameters, but the med was given when the BP was below the ordered threshold on 2 occasions. An CMT and the DON both acknowledged the med should have been held, and the DON could not provide evidence that the resident was kept free from unnecessary meds.
A resident with severe cognitive impairment sustained second-degree burns from an electric baseboard heater due to improper bed placement against the wall. The heater's temperature was recorded between 163-190°F, and the manufacturer's instructions required a 12-inch clearance, which was not maintained. Staff interviews confirmed that multiple beds were positioned against walls with heaters, posing a risk to residents.
A resident with dementia was subjected to derogatory and threatening remarks by an RN, who was overheard by other staff making statements such as "you're disgusting" and "I wish I could punch you in the face." The incident was reported by a NA and corroborated by another RN. The resident was noted to be agitated during the shift, and the RN involved was suspended pending investigation.
A facility failed to investigate an alleged abuse incident where a resident was seen assisting another resident of the opposite sex in putting on pants and kissing. The DNS could not provide evidence of a comprehensive investigation or report the incident to the Department of Health. The involved residents had significant medical histories and cognitive conditions, yet the facility did not follow its policy for timely investigation and documentation.
The facility failed to serve milk at the proper temperatures during lunch meals and did not maintain cleanliness in the main kitchen. Milk temperatures were found to be above the acceptable limit of 41 degrees Fahrenheit, and grease accumulation was observed on the screens and inner sides of the hood above the stove. The Certified Dietary Manager acknowledged these issues.
A resident with anxiety exhibited signs of distress during a dressing change, and the LPN was unaware of the physician's order for as-needed Lorazepam. The Assistant DON confirmed that the nurse should have medicated the resident prior to the procedure or stopped to administer the medication, indicating a lapse in communication and adherence to prescribed treatments.
A facility failed to provide a resident with necessary behavioral health care and services, including a recommended psychotherapy consultation and ear plugs for insomnia. Despite multiple diagnoses and medication adjustments, the resident's care plan was not fully implemented, leading to continued issues with insomnia and lack of psychotherapy.
A facility failed to document and report changes in a hospice resident's skin condition to the hospice provider or physician. The resident had multiple dark reddened areas that were not documented or reported by the LPN who noticed them. The facility's procedure to contact hospice services for wound care recommendations was not followed, and the Assistant Director of Nursing Services acknowledged the failure when it was brought to their attention by the surveyor.
The facility failed to maintain an infection prevention and control program, as evidenced by two staff members not adhering to proper PPE and hand hygiene protocols. A nurse entered the room of a resident with ESBL without donning a gown and gloves, and another nurse administered eye drops without wearing gloves and failed to perform hand hygiene.
Failure to Notify Residents of Personal Needs Fund Balance Limits
Penalty
Summary
The facility failed to notify residents, or their resident representatives, in writing when Medicaid personal needs fund balances reached $200 less than the SSI resource limit of $4,000. Based on record review, Resident ID #42, Resident ID #45, and Resident ID #93 each had personal needs funds managed by the facility and their account balances exceeded the $4,000 resource eligibility guideline during the reviewed periods. Resident ID #42’s quarterly statements showed ending balances of $4,632, $4,858.28, and $5,008.71 on 2/3/2026. Resident ID #45’s statements showed ending balances of $4,073.80, $4,299.30, $4,448.64, and $4,484.22 on 5/1/2026. Resident ID #93’s statement landscape showed a balance of $4,115.18 on 4/10/2026. During interview, the Business Office Manager acknowledged that these residents were over the resource eligibility guideline for the dates reviewed and was unable to provide evidence that the residents and/or their representatives were notified in writing when their account balances reached $200 less than the SSI Medicaid eligibility resource limit of $4,000. The deficiency was identified during survey review of resident personal needs fund records and staff interview.
Late and Missing MDS Assessments
Penalty
Summary
The facility failed to electronically transmit encoded, accurate, and complete MDS data to CMS within the required timeframes for several residents. For Resident ID #50, who was admitted with diagnoses including stroke and lung cancer and later discharged, a Quarterly MDS with an ARD of 12/29/2025 was not opened and completed until 5/12/2026 and was transmitted on 5/14/2026, more than 4 months after the ARD. For Resident ID #71, who had diagnoses including COPD and depression, an Annual MDS with an ARD of 4/1/2026 was opened on 5/7/2026, completed on 5/12/2026, and transmitted on 5/14/2026, 41 days after the ARD. For Resident ID #106, who was admitted with diagnoses including stroke and type II diabetes and later discharged, a Quarterly MDS with an ARD of 10/17/2025 was completed and transmitted on 5/10/2026, more than 6 months after the ARD. The facility also failed to complete and transmit required assessments for other residents. Resident ID #75, who had diagnoses including dementia and depression and was admitted to hospice services on 4/3/2026, required a Significant Change in Status Assessment because hospice enrollment triggers that assessment; the SCSA with an ARD of 4/15/2026 was completed on 4/28/2026, 12 days late. Resident ID #94 was reviewed as a discharged resident, and the facility failed to complete and transmit a discharge MDS Assessment for that resident. During interview, the Regional MDS Coordinator acknowledged the late completion and transmission of the assessments and was unable to provide evidence that the MDSs were completed and transmitted within the timeframes stated in the RAI manual and facility policy.
Failure to Replace CPAP and BiPAP Supplies per Manufacturer Guidance
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met when the facility failed to provide respiratory care in accordance with professional standards of practice for 3 of 3 residents who required non-invasive positive airway pressure therapy. Resident ID #6 had diagnoses including COPD and obstructive sleep apnea, was assessed as using a non-invasive mechanical ventilator, and had orders to clean the CPAP mask and tubing weekly and to use CPAP at bedtime. The record did not show orders to replace the air filters, masks, mask frame, chin straps, or humidifier water chamber per the manufacturer’s recommendations. Resident ID #7 had obstructive sleep apnea, was also assessed as using a non-invasive mechanical ventilator, and had orders to clean the CPAP machine, hose, and mask weekly and to apply CPAP at bedtime and remove it in the morning. The record did not show orders to replace the disposable air filter, cushions, mask frame system, air tubing, or humidifier water chamber per the manufacturer’s recommendations, and the resident stated the mask in use was from prior to admission and could not recall when it was last replaced. Resident ID #35 had COPD and obstructive sleep apnea, was assessed as using a non-invasive mechanical ventilator, and had orders for BiPAP use every evening and night shift and to clean the BiPAP mask and tubing weekly. The record did not show orders to replace the air filters, masks, mask frame, chin straps, or humidifier water chamber filter per manufacturer recommendations, and the resident could not recall when those items were last replaced. The DON was unable to provide evidence that the CPAP and BiPAP equipment for these residents had been or were scheduled to be replaced per manufacturer recommendations.
Failure to Provide Written Notice Before Room or Roommate Changes
Penalty
Summary
The facility failed to provide written notice, including the reason for a room or roommate change, before changing the room or roommate for 2 residents reviewed. A facility policy titled Room Changes dated 10/15/2020 stated that residents would receive written notice of a room or roommate change and that the notice would be delivered in a reasonable amount of time prior to the planned change. Resident ID #3 was readmitted in March 2026 with diagnoses including anxiety disorder, major depressive disorder, and dementia, and an admission MDS showed a BIMS score of 12 out of 15. During observation on 5/14/2026 at 12:34 PM, the Admissions Director was seen moving Resident ID #59's belongings into Resident ID #3's room. Resident ID #3 stated s/he was not informed about getting a roommate until the personal items were being moved in, and the record did not show prior notification to the resident or representative. Resident ID #59 was admitted in May 2026 with diagnoses including neuromuscular dysfunction of bladder and complications of a urinary catheter, and an admission MDS showed a BIMS score of 15 out of 15. Progress notes showed Resident ID #59 was out of the facility for a scheduled community appointment at the time of the room change, and there was no evidence that the resident was informed of the room change while away. The record also did not show written notice of the room change, the reason for the change, or consent before the observation. The Admissions Director stated the facility was receiving a new admission requiring precautions, that she moved Resident ID #59's personal items while the resident was out for ease, and that she had not informed Resident ID #3 until the items were being moved or documented consent from Resident ID #59.
Failure to Document Ordered PICC Line Measurements
Penalty
Summary
The facility failed to ensure that a resident with a PICC line received treatment and care in accordance with physician orders and the comprehensive person-centered care plan. The resident was admitted in April 2026 with a diagnosis including sepsis due to methicillin susceptible staphylococcus aureus and had orders for PICC line dressing changes and for measurement of external catheter length, with arm circumference added in a later order. The record showed an external catheter length of 4 mm and arm circumference of 30 cm on 4/19/2026, an external catheter length of 9.5 cm with no documented arm circumference on 4/26/2026, and no documented measurements on 5/6/2026 or 5/13/2026. Further review did not reveal evidence that the resident's arm circumference and external catheter length were measured and documented as ordered. During interview, the RN stated the orders to obtain the PICC line measurements were documented as completed, but the measurements were not documented in the TAR. The DON was unable to provide evidence that the resident's PICC line external catheter length and arm circumference were measured weekly per physician orders.
Unnecessary Medication Administration Despite Hold Parameters
Penalty
Summary
The facility failed to ensure that Resident ID #6’s drug regimen was free from unnecessary drugs when metoprolol succinate 25 mg was administered despite physician-ordered hold parameters. The resident was admitted in August 2025 with diagnoses including chronic kidney disease and hypertension, and had an order for metoprolol succinate 25 mg on Monday, Wednesday, Friday, and Sunday for hypertension with instructions to hold the medication if systolic blood pressure was less than 110. Review of the May 2026 MAR showed the medication was given on 2 of 8 opportunities when the resident’s blood pressure was below the ordered parameter, including readings of 100/48 and 102/74. During interviews, the Certified Medication Technician acknowledged the medication should have been held on both occasions, and the DNS also acknowledged the medication was administered when it should have been held and was unable to provide evidence that the resident was kept free from unnecessary medications.
Resident Burned by Electric Baseboard Heater Due to Improper Bed Placement
Penalty
Summary
The facility failed to maintain a safe environment for a resident, resulting in the resident sustaining second-degree burns from an electric baseboard heating unit. The incident occurred when the resident's foot was found resting directly on the heating unit, which was positioned against the wall next to the resident's bed. The heating unit's temperature was recorded between 163-190 degrees Fahrenheit, which is hot enough to cause burns upon contact. The manufacturer's instructions for the heating unit specified a minimum clearance of 12 inches from any objects, which was not adhered to in this case. The resident involved had a history of neurocognitive disorder with Lewy bodies dementia and muscle wasting and atrophy, and was assessed to have severely impaired cognition. The resident required supervision and assistance with transfers and bed mobility. On the night of the incident, a nursing assistant found the resident's foot on the heating unit, resulting in significant burns that required hospital admission. The resident was unable to verbalize pain but showed signs of discomfort and pain through facial grimacing and attempts to pull the foot away during assessment. Interviews with staff revealed that the resident's bed, along with others in the facility, was positioned against the wall where the heating units were located, contrary to safety guidelines. The Maintenance Director confirmed the high temperatures of the heating units and acknowledged the need for a 12-inch clearance. The facility was unable to provide evidence that they ensured the resident environment was free from accident hazards, which placed residents at risk of serious harm.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, as evidenced by an incident involving a registered nurse (RN), Staff B, and a resident with moderately impaired cognition due to dementia. The incident was reported by a nursing assistant (NA), Staff A, who overheard RN, Staff B, making derogatory and threatening remarks to the resident, including statements such as "you're disgusting" and "I wish I could punch you in the face." This behavior was corroborated by another RN, Staff C, who also heard Staff B telling the resident to "shut up" and calling them "disgusting." The resident, who was readmitted to the facility in September 2021, was noted to have been agitated during the shift, as documented by Staff B in a progress note. The incident occurred during the evening shift, and attempts to interview the alleged perpetrator, Staff B, were unsuccessful. The resident involved refused to speak with the surveyor. The facility's administrator acknowledged the incident and confirmed that Staff B had been suspended pending investigation. The deficiency highlights a failure in maintaining an environment that promotes the dignity and respect of residents, particularly those with cognitive impairments.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to provide evidence of a thorough investigation into an alleged abuse incident involving two residents. A staff member observed one resident assisting another resident of the opposite sex in putting on pants and witnessed them kissing. Despite the facility's policy requiring immediate investigation and documentation of such incidents, the Director of Nursing Services (DNS) was unable to provide evidence of a comprehensive investigation, including witness statements from the involved residents and a roommate who reportedly witnessed the incident. Additionally, the incident was not reported to the Department of Health as required. The residents involved had significant medical histories and cognitive conditions. One resident, admitted in April 2023, had a history of HIV, chronic Hepatitis B and C, and exhibited sexualized behaviors, with a BIMS score indicating intact cognition. The other resident, admitted in September 2020, had neurocognitive disorder and moderate cognitive impairment, with a history of poor decision-making and boundary issues. Despite these factors, the facility did not conduct a timely and comprehensive investigation or report the incident to the appropriate authorities, as required by their policy.
Improper Food Serving Temperatures and Kitchen Cleanliness
Penalty
Summary
The facility failed to properly serve food and maintain equipment in accordance with professional standards for food safety. Specifically, the serving temperatures of whole milk during lunch meals on multiple dates were found to be above the acceptable limit of 41 degrees Fahrenheit. On 4/19/2024, the milk served in the Main Dining Room was at 53.1 degrees F, at the Water Street nursing unit it was 51.6 degrees F, and at the Canary Street nursing unit it was 43.1 degrees F. These temperatures were observed by the surveyor and acknowledged by the Certified Dietary Manager during an interview on 4/19/2024 at approximately 2:30 PM. Additionally, the facility failed to maintain the cleanliness of nonfood-contact surfaces in the main kitchen. The surveyor observed visible grease accumulation on the screens in the hood above the stove and encrusted grease along the inner sides of the hood on three separate occasions: 4/17/2024 at approximately 9:30 AM, 4/18/2024 at approximately 11:30 AM, and 4/19/2024 at approximately 11:45 AM. The Certified Dietary Manager acknowledged the grease accumulation during the interview on 4/19/2024.
Failure to Administer Anxiety Medication as Prescribed
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for a resident with anxiety. The resident, who was admitted with diagnoses including dementia, cognitive communication deficit, conductive hearing loss, glaucoma, and anxiety, had a physician's order for Lorazepam to be administered as needed for anxiety, restlessness, or agitation. During a dressing change, the resident exhibited signs of anxiety and repeatedly called out to the nurse to stop. The Licensed Practical Nurse (LPN) performing the dressing change was unaware of the order for the as-needed anxiety medication until it was brought to her attention by the surveyor. The Assistant Director of Nursing Services confirmed that the expectation was for the nurse to medicate the resident prior to the dressing change or stop the treatment and administer the anxiety medication as per the physician's order. The failure to follow the physician's order for the anxiety medication resulted in the resident experiencing unnecessary anxiety during the dressing change. This incident highlights a lapse in communication and adherence to prescribed medical treatments within the facility.
Failure to Provide Necessary Behavioral Health Care and Services
Penalty
Summary
The facility failed to ensure that a resident received necessary behavioral health care and services to maintain their highest practicable well-being. The resident, admitted in July 2023, had diagnoses including PTSD, panic disorder, anxiety, and major depressive disorder. Despite a care plan initiated on 8/1/2023 that included interventions such as utilizing psych services, the resident did not receive the recommended psychotherapy consultation. The resident's medication records showed multiple prescriptions for managing depression, anxiety, and insomnia, but there was no evidence of follow-up on the psychotherapy recommendation made by the contracted psych services APRN on 3/11/2024 and reiterated on 4/4/2024. Additionally, the resident complained of insomnia due to environmental factors, such as a loud roommate and an open door, and requested doxepin. Although alternative solutions like ear plugs were suggested, the resident reported not receiving them. Interviews with the resident and staff confirmed that the psychotherapy recommendations were not followed up on, and the resident did not receive the ear plugs. The Director of Nursing Services acknowledged that nursing should have followed up on the psych recommendations and that the Social Worker should have provided the ear plugs.
Failure to Document and Report Changes in Skin Condition for Hospice Resident
Penalty
Summary
The facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and that the communication process between the facility and the hospice provider meets the needs of the resident. Specifically, for one resident receiving hospice services, the facility did not document or report changes in skin condition to the hospice provider or physician. The resident, admitted in September 2019 with diagnoses including dementia and the need for assistance with personal care, had a care plan revised in August 2023 that included notifying hospice of any change in condition and documenting/reporting any changes in skin status. During a surveyor observation, the resident was found to have multiple dark reddened areas on the lower shin and foot, which had not been documented or reported by the LPN who first noticed the changes two days prior. Further review revealed that the facility's procedure to contact hospice services for wound care recommendations was not followed, and the Assistant Director of Nursing Services acknowledged the failure to communicate these recommendations to the hospice provider until it was brought to their attention by the surveyor.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by two staff members not adhering to proper PPE and hand hygiene protocols. Specifically, a Registered Nurse entered the room of a resident with ESBL without donning a gown and gloves, despite the resident being on contact precautions. The nurse acknowledged the oversight during an interview. The resident had a diagnosis of ESBL resistance and was receiving intravenous antibiotics, making adherence to contact precautions critical. Additionally, a Licensed Practical Nurse administered eye drops to another resident without wearing gloves and failed to perform hand hygiene after removing the gloves. The nurse only donned gloves after being prompted by the surveyor and did not wash hands before exiting the room. The Director of Nursing Services could not explain why the staff failed to follow the facility's infection control policies during an interview conducted in the presence of the Administrator and Assistant Director of Nursing Services.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near North Kingstown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Roberts Health Centre Inc | 1.4 mi | ★★★★★ | 5 | 0 |
| Saint Elizabeth Home East Greenwich | 5.5 mi | ★★★★★ | 5 | 0 |
| South Kingstown Nurs. & Rehab Ctr | 5.6 mi | ★★★★★ | 9 | 1 |
| Bayview Rehabilitation And Healthcare Center | 6.4 mi | ★★★★★ | 5 | 1 |
| Kingston Center For Rehabilitation And Health Care | 6.9 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.